title: Appropriateness of prescribing among elderly patients in a Dutch residential home: observational study of outcomes after a pharmacist-led medication review.
abstract: BACKGROUND
  Clinically significant pharmacokinetic and pharmacodynamic changes occurring with age make older patients more prone to the consequences of inappropriate prescribing. The combination of higher use of medicines resulting from a higher disease burden with suboptimal treatment monitoring results in a higher risk of unwanted drug effects from sometimes inappropriate choice of drugs, doses and durations of treatment. Pharmacy services are increasingly being targeted to minimize the overall number of unnecessary and potential harmful medicines.
  
  
  OBJECTIVE
  To investigate the impact of a pharmacist-led medication review on quality of prescribing by a healthcare professional team consisting of a general practitioner (GP), care home staff and a pharmacist.
  
  
  METHODS
  This observational study compared outcome measurements before and after a pharmacist-led review of medications for patients under the care of a healthcare professional team consisting of a GP, care home staff and pharmacist. The procedure for conducting and recording the medication review consisted of the preparation of a patient medication profile, which combined the patient's medical records with his or her complete prescription record (current and previous [last 3 years] medication history) and pharmaceutical record (electronic journal entries for the patient over the same period). Laboratory values were evaluated in clinical context. Recommendations for the pharmaceutical plan were discussed at a conference involving the clinical pharmacist and other healthcare team members. Patients were recruited for medication review over the 12-month period 1 April 2003 to 1 April 2004. Medication appropriateness was assessed by an independent panel of clinical pharmacists using the Medication Appropriateness Index (MAI).
  
  
  RESULTS
  A total of 54 patients were eligible according to the inclusion criteria, of whom 24 were subsequently excluded for various reasons; thus, 30 patients were eligible for assessment on the MAI. There was a statistically significant difference between overall pre- and post-intervention summed MAI scores (p=0.013). The pharmacist identified 115 drug-related problems, and the total number of accepted recommendations was 78 (67.8%). Use of a medication review as an intervention by a clinical pharmacist was associated with an improvement in appropriateness of prescribing.
  
  
  CONCLUSIONS
  This study provides evidence supporting the formal integration of a clinical pharmacist into the healthcare team with the aim of improving prescribing appropriateness for institutionalized elderly Dutch patients. Overall MAI scores for all long-term medications used by a group of elderly patients improved significantly after a pharmacist-led medication review. This is an important finding because quality of prescribing is assuming increasing importance as a means of preventing avoidable medication-related harm.
authors.affiliation: Department of Pharmacy, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands. ccmstuijt@hetnet.nl
authors.forename: Clementine C M
authors.initials: CC
authors.lastname: Stuijt
authors.forename: Eric J F
authors.initials: EJ
authors.lastname: Franssen
authors.forename: Antoine C G
authors.initials: AC
authors.lastname: Egberts
authors.forename: Steve A
authors.initials: SA
authors.lastname: Hudson
mesh_terms: D000368:Aged / Q000706:statistics & numerical data*; D000369:Aged, 80 and over; D003627:Data Interpretation, Statistical; D004347:Drug Interactions; D017723:Drug Utilization Review / Q000379:methods*; D005260:Female; D006282:Health Personnel; D006801:Humans; D008297:Male; D009426:Netherlands; D010593:Pharmaceutical Services / Q000592:standards; D010594:Pharmacies; D010595:Pharmacists; D010821:Physicians, Family; D055656:Prescriptions / Q000592:standards*; D012112:Residential Facilities / Q000706:statistics & numerical data*; D000078329:Workforce